We propose to investigate the interactive effects of substance abuse and rurality on the clinical outcomes of schizophrenia in a prospective longitudinal study. No study has yet examined the clinical outcomes associated with substance abuse in rural areas, despite the fact that substance abuse is the most prevalent comorbid condition associated with schizophrenia. Further, rural areas lack specialized mental health care services to deal with such specialized needs. Currently, gaps in our knowledge prevent us from being able to target problem areas for these patients and to develop effective and accessible services for this population. Consequently, the proposed study will address these gaps by answering two questions: What are the clinical outcomes of patients with schizophrenia and comorbid substance abuse in rural areas? and What patient and mental health service factors account for urban and rural differences in clinical outcomes for patients with substance abuse and schizophrenia? The study design involves following 192 patients for eighteen months after an index hospitalization. Patients from one urban and three quite different rural areas will be assessed on multiple domains through clinical interviews as well as through family and mental health professional informants. The aim of data analysis will be to understand the unique outcomes of substance abuse in rural areas for patients with schizophrenia. We will employ regression techniques to examine the interactive effects of rurality and substance abuse controlling for patient and mental health service access and utilization factors. Results will guide treatment efforts in rural areas by giving information about what clinical outcomes are most affected by substance abuse and pointing to patient, services, and community factors that are related to these outcomes.